Standard Operating Procedure 1 (SOP 1)
Writing an Operational Policy
Why we have a procedure?
Several recommendations arising from serious incident reviews have requested that
individual teams/services/units maintain an up-to-date operational policy as an easy,
accessible reference for new and existing staff, with the aim of reducing incidents and
risks.
An operational policy provides a framework to capture key information regarding service
delivery and service arrangements. It should outline the context of the service, explain the
service philosophy of care and give clear referral and assessment procedures. The policy
should further provide staff, patients, carers and other stakeholders with clear guidance
and understanding of a team or service’s role, function and objectives.
What overarching policy the procedure links to?
Policy for the Development and Management of Procedural Documents
Which services of the trust does this apply to? Where is it in operation?
Group
Mental Health Services
Learning Disabilities Services
Children and Young People Services
Inpatients
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Community
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Teams/Units
all
all
all
Who does the procedure apply to?
Operational leads / Senior operational staff with experience of report and policy
writing
Group Governance staff to advise and support them in this task as necessary
When should the procedure be applied?
In circumstances where a new service/team/unit is established a new policy should
be produced
Where an existing team/service undergoes significant operational change the policy
should be updated to reflect the new operational arrangements
Annual review by service manager / operational lead to ensure it is monitored and
continues to reflect current operational arrangements and service delivery
How to carry out this procedure
At the present time, the Trust has not created a specific template to use for all operational
policies. The diverse range of teams and services in operation across the organisation
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does not lend itself to being so prescriptive with a one size fits all. However, listed below
are suggested headings and bullet point prompts for consideration. It is NOT necessary to
use each heading - only for what you decide is relevant to your team/ service. Equally, the
amount of text to include for each relevant heading will vary according to the operation of
each team or service.
Team Model and Structure
1. Purpose of the policy
- To outline the service/unit/team’s main aim and purpose of operation
- How the service/unit/team delivers care
- Clear information about roles within the service/unit/team
- Key principles involved in delivery care
- Guidance document for new and existing staff
2. Philosophy and model of care
- Relevant standards and guidance
- Trust profile and local need
- Vision and values
- Specific therapeutic interventions
3. Introduction
- Clinical setting (inpatient, community, A&E)
- Service context (substance misuse, CAMHS etc.)
- Funding and management stakeholders
- Catchment area
- Age range
4. Staffing levels
- Management structure
- Different disciplines
- Role and responsibilities
5. Hours of operation and service provision
- Opening hours
- Visiting times
- Out-of hours contacts
- Contacting the team in and out of hours
- Duty systems
- Handover arrangements
6. Team meetings
- Clinical and business
- Minutes and recordings
7. Supervision and leadership
- Roles of management figures
- Supervisors/supervisees within the team
- Management supervision
- Professional supervision
- Clinical supervision
- Documentation of supervision
- Induction process of new staff to the team (bank and otherwise)
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Clinical Processes
8. Referral
- Referral agencies
- Referral procedures (urgent, non-urgent, re-referral, self-referral) and process
- Inclusion and exclusion criteria
9. Assessment
- Disciplines involved
- Case status
- Documentation
- Timeframe
- Communication with referrers
10. Allocation and co-ordination of care
- Outpatient clinics
- Duty system
- Care co-ordination
- Non-care co-ordination
- Other
11. Medication arrangements
- TTAs
- Depot clinics
- FP10 prescribing
- Administration arrangements
- Medicines reconciliation
12. Discharge procedures
- Discharge planning
- Discharge delivery
- Discharge communication
- Transfer of care
13. Service-user and carers involvement
- Care planning
- Risk assessment and care planning
- Signing and copies of care plans
- Carers assessments
- Direct patients/personal budgets
- Advance directives
- Crisis and contingency planning
14. Team documentation
- Referral forms (accessibility)
- Permission to share
- Assessment Forms
- Specific care plans
- CPA care plan
- Crisis and contingency plans
- Additional assessment and planning tools
- Discharge notification forms
- Discharge summaries and correspondence
15. Safeguarding Children and Vulnerable Adults
- Responsibilities of individual team members
- Brief outline of reporting arrangements
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Children visiting rooms (inpatient)
Children being on Trust premises
16. Equality and Diversity
- Access to interpreting
- Access to faith services
17. Liaison with other teams/agencies
- Liaison with GPs
- Attendance at CPAs, management and ward rounds
- Inpatient GP services
Quality Governance
18. Information Governance
- Permission to share forms cover all data subject information
- Subject access requests
- Informing patients when their personal information is used or misused
19. OASIS /Care Records
- Opening and closure of patients
- Contact recordings
- Clinical document upload
- Progress note recording
20. Management of clinical case files
- Storage of files
- Management of individual file content
- Reporting of lost files
21. Incident management
- Reporting
- Remedial action
- Roles and responsibilities
- Documentation
- Securing evidence e.g. case files
22. Health and Safety
- Roles and responsibilities
- Risk Assessments
- Security (alarm systems, CCTV etc.)
- Emergency procedures
23. Governance: quality, safety and performance monitoring
- Clinical audit (audit reps and specific team programme)
- CQC compliance
- Complaints (formal and informal)
- Learning from complaints, incident reviews and other feedback mechanisms
- Key performance indicators
24. Implementation and monitoring of the operational policy
- Annual review by service manager / operational lead
25. References
- Trust policies
- Group policies
- National Guidance
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Consultation records/minutes
Approval Process
When a new operational policy has been written or an existing policy updated, it should be
passed to the Service Manager and the General Manager for approval.
Thereafter, the Service Manager should arrange for the operational policy to be ratified by
the Quality and Safety Group and minuted accordingly. At that point, the policy becomes
operational.
A copy of the ratified operational policy should be forward to the Corporate Governance
Assurance Unit, who are responsible for uploading policies to the intranet, and archiving
the previous policy where there is one; this is important in the event of a future claim
against the trust.
Where do I go for further advice or information?
Service Manager, Group General Manager, Group Director
Group Divisional staff
Corporate Governance staff
Training
Staff may receive training in relation to this procedure, where it is identified in their
appraisal as part of the specific development needs for their role and responsibilities.
Please refer to the Trust’s Mandatory & Risk Management Training Needs Analysis for
further details on training requirements, target audiences and update frequencies
Monitoring / Review of this Procedure
In the event of planned change in the process(es) described within this document or an
incident involving the described process(es) within the review cycle, this SOP will be
reviewed and revised as necessary to maintain its accuracy and effectiveness.
Equality Impact Assessment
Please refer to overarching policy
Data Protection Act and Freedom of Information Act
Please refer to overarching policy
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Standard Operating Procedure Details
Unique Identifier for this SOP is
BCPFT-GOV-SOP-01-1
State if SOP is New or Revised
New
Policy Category
Governance
Executive Director
whose portfolio this SOP comes under
Policy Lead/Author
Job titles only
Executive Director of Nursing, AHPs and
Governance
Committee/Group Responsible for
Approval of this SOP
Compliance Lead
Divisional Quality and Safety Steering Group
Month/year consultation process
completed
Month/year SOP was approved
August 2015
Next review due
September 2018
Disclosure Status
‘B’ can be disclosed to patients and the public
Key Words for this SOP
Service delivery, Service arrangements,
Context of service, Service philosophy of care,
Referral and assessment procedures,
Team/service role, functions and objectives,
Clinical processes, Approval process
Review and Amendment History - to be completed by Corporate Governance
Version
Date
V1.0
Sep
2015
Description of Change
New Procedure established to supplement Policy for Procedural
Documents based on recommendations arising from serious incident
reviews
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